Margot Fleuren

Implementation of a shared care guideline for back pain: Effect on unnecessary referrals

Objective To determine the effect of the implementation of a shared care guideline for the lumbosacral radicular syndrome (LRS) on unnecessary early referrals and the duration of the total diagnostic procedure. Design Introduction of shared care guideline in November 2005. Pre-test in 2005 (April to October), a first post-test in 2006 (April to October) and a second post-test in 2007 (April to October). Setting and Intervention The introduction of a shared care guideline derived from national guidelines for GPs and several medical/paramedical specialists in two Dutch regions. Three hundred and sixty GPs, 550 physiotherapists and two hospitals (9 neurologists and 18 radiologists) were involved. The essential component of the guideline was a trade-off: if the GP complied with the conservative management approach in the first 6 weeks, the hospital guaranteed a priority appointment with the neurologist after 6 weeks, if still required. Main Outcome Measures The neurologists in both hospitals registered whether a patient had been unnecessarily referred during the first 6 weeks. The duration of the total diagnostic procedure was defined as the number of days between referral by the GP and the consultation when the neurologist made the final diagnosis. Results The percentage of patients being unnecessarily referred within 6 weeks fell significantly from 15% in 2005 to 9% in 2006 and 8% in 2007. The duration of the total diagnostic procedure also fell significantly in both the long and short terms. Conclusions The introduction of a shared care guideline for all care providers in a region reduces the number of unnecessary early referrals for patients with LRS.

A systematic approach to implementing and evaluating clinical guidelines: The results of fifteen years of Preventive Child Health Care guidelines in the Netherlands.

Preventive Child Health Care (PCHC) services are delivered to all children in the Netherlands by approximately 5500 doctors, nurses and doctors assistants. In 1996, The Dutch Ministry of Health, Welfare and Sports asked for the development of evidence-based PCHC guidelines. Since 1998, twenty-five guidelines have been published. Levels of implementation affect outcomes and so implementation and evaluation of the actual use of guidelines are essential. At the outset, there was a national implementation plan with six main activities: a) determinant analysis before the implementation of a guideline, b) innovation strategies tailored to the determinants, c) dissemination to all professionals, d) ongoing evaluation of the awareness and use of the guidelines, e) trained implementation coordinator(s) in each PCHC organization and f) a national help desk. The awareness and use of the guidelines in random samples of doctors, nurses and doctors assistants were surveyed using questionnaires. The respondents stated (on a 7-point scale) the proportion of all children they had exposed to given core elements in a guideline. The aim is for at least 90% of the professionals to be aware of the guideline and for 80% to perform the core elements for all (or nearly all) children. The six main activities, with the exception of ongoing evaluation, were gradually put into place, albeit only gradually, between 1998 and 2015 for all guidelines. In 2012, the use of individual core elements in all guidelines, dating from before 2012, varied from 28% to 100%. One guideline met both criteria of 90% awareness and 80% use, and three guidelines nearly met these criteria. Looking back on fifteen years of PCHC guidelines, we may conclude that the guidelines produced recently are implemented in accordance with the national implementation plan. Unfortunately, the evaluation of guideline use continues to be a difficulty.

Checklist determinanten van innovaties in gezondheidszorgorganisaties

SamenvattingChecklist for determinants of innovations in health care organizationsIn 2006 we published an article on 50 determinants of innovations in health care organizations. A brief description of all determinants and their influence was given. Implementation researchers and implementation consultants or advisors have asked us repeatedly to publish a full description of the determinants. The full description of the determinants and an indication of the influence of both extremes of a determinant (e.g. low vs high staff turnover) on the innovation process are given in this article.Keywords: implementation, determinants, innovations, health care organizations, checklist

Implementation of a cost-effective strategy to prevent neonatal early-onset group B haemolytic streptococcus disease in the Netherlands

BackgroundEarly-onset Group B haemolytic streptococcus infection (EOGBS) is an important cause of neonatal morbidity and mortality in the first week of life. Primary prevention of EOGBS is possible with intra-partum antibiotic prophylaxis (IAP.) Different prevention strategies are used internationally based on identifying pregnant women at risk, either by screening for GBS colonisation and/or by identifying risk factors for EOGBS in pregnancy or labour. A theoretical cost-effectiveness study has shown that a strategy with IAP based on five risk factors (risk-based strategy) or based on a positive screening test in combination with one or more risk factors (combination strategy) was the most cost-effective approach in the Netherlands. IAP for all pregnant women with a positive culture in pregnancy (screening strategy) and treatment in line with the current Dutch guideline (IAP after establishing a positive culture in case of pre-labour rupture of membranes or preterm birth and immediate IAP in case of intra-partum fever, previous sibling with EOGBS or GBS bacteriuria), were not cost-effective. Cost-effectiveness was based on the assumption of 100% adherence to each strategy. However, adherence in daily practice will be lower and therefore have an effect on cost-effectiveness.Method/DesignThe aims are to: a.) implement the current Dutch guideline, the risk-based strategy and the combination strategy in three pilot regions and b.) study the effects of these strategies in daily practice. Regions where all the care providers in maternity care implement the allocated strategy will be randomised. Before the introduction of the strategy, there will be a pre-test (use of the current guideline) involving 105 pregnant women per region. This will be followed by a post-test (use of the allocated strategy) involving 315 women per region. The outcome measures are: 1.) adherence to the specific prevention strategy and the determinants of adherence among care providers and pregnant women, 2.) outcomes in pregnant women and their babies and 3.) the costs of each strategy in relation to the effects.DiscussionThis study will provide recommendations for the implementation of the most cost-effective prevention strategy for EOGBS in the Netherlands on the basis of feasibility in daily practice.Trial registrationDutch Trial Register, NTR3965

Begrippenkader voor het ‘wat’ en het ‘waarom’ bij implementatie van vernieuwingen in patiëntenzorg en preventie

SamenvattingOm ervaringen uit te wisselen en kennis op te bouwen zijn eenduidige en gedeelde begrippen nodig. Hoewel er in Nederland veel aandacht wordt besteed aan implementatie, ontbreken dergelijke begrippen voor het benoemen van implementatiestrategieën en beïnvloedende factoren. Daarom werd een project uitgevoerd dat tot doel had om deze te ontwikkelen. Het begrippenkader kwam tot stand door middel van literatuuronderzoek, besprekingen in de projectgroep, en toetsing bij 20 potentiële gebruikers van het begrippenkader. Het begrippenkader bestaat uit twee componenten: een korte typering van implementatiestrategieën (‘wat’) en beïnvloedende factoren bij implementatie (‘waarom’). Implementatiewerkers en –onderzoekers worden uitgenodigd dit begrippenkader te gebruiken bij de beschrijving van hun activiteiten.AbstractConceptual framework for the ’what’ and ’why’ in implementation of innovations in patient care and preventionA standardised and shared set of constructs is needed for effective exchange of experiences and development of evidence. While implementation has received much interest in The Netherlands, such set was not available for describing implementation interventions and determinants of change. Our project aimed to develop such set of constructs. The set was developed on the basis of literature review, discussion in the project group, and assessment in 20 potential users of the constructs. The set of constructs comprises two components: a short qualification of implementation interventions (‘what’) and of determinants for change (‘why’). Researchers and workers in the field of implementation are encouraged to use the constructs in descriptions of their activiteits.

Condities voor effectieve invoering van jeugdinterventies: een kennissynthese

SamenvattingHet onderzoek van de afgelopen twintig jaar in de gezondheidszorg laat zien dat richtlijnen en interventies zichzelf niet implementeren. Deze notie is relevant tegen de achtergrond van het groeiend aantal richtlijnen en (effectieve) interventies dat voor de jeugdsector de afgelopen jaren is ontwikkeld en nog wordt ontwikkeld. We bedoelen hier de sectoren jeugdgezondheidszorg, jeugdzorg en jeugdwelzijn. De invoering van effectieve interventies laat binnen de jeugdzorg vooralsnog te wensen over.1 De invoering van richtlijnen in de jeugdgezondheidszorg (JGZ) verloopt redelijk. Inmiddels is er de nodige kennis en ervaring aanwezig over de condities voor de invoering en borging van deze richtlijnen. 2-5 Binnen het werkveld jeugdwelzijn zijn nagenoeg geen effectieve interventies ontwikkeld en ingevoerd. Dat vraagt om een gewijzigde aanpak willen 0-19 jarigen / jongeren kunnen profiteren van de kennis die al is ontwikkeld. In dit artikel wordt beschreven hoe we de kansen op een succesvolle invoering kunnen vergroten.AbstractSystematic introduction of innovations in youth (health) careTo obtain insight into strategies for effectively implementing innovations in youth (health) care, we carried out a literature study on 13 innovation reviews (published between 2000 and 2009). Furthermore, we studied the introduction of seven interventions in youth care. Afterwards, an expert meeting with researchers, policy makers and implementation consultants was organised to discuss the outcomes. The main conclusion is that the actual use of innovations is maximised if they are systematically introduced. This means that first an analysis of determinants of the innovation process is performed and that innovation strategies are adapted to these determinants. The article gives practical guidelines for introducing innovations systematically.

Do patients matter? Contribution of patient and care provider characteristics to the adherence of general practitioners and midwives to the Dutch national guidelines on imminent miscarriage

Objective—To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers. Design—Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage. Setting—General practices and midwifery practices in the Netherlands. Subjects—73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months. Main measures—Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place. Results—In the multilevel model explaining variance in adherence to physical examinations, the care providers acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level. Conclusions—The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions. (Quality in Health Care 2000;9:106–110)

Feasibility of guidelines for the management of threatened miscarriage in general practice/family medicine

Objective: to determine the feasiblity in daily practice of guidelines on threatened miscarriage for general practice. The guidelines on threatened miscarriage were issued in 1989 by the Dutch College of General Practitioners. Methods: prospective recording of appointments by 86 general practitioners (GPs) in the Netherlands, who agreed to adhere to the threatened miscarriage guidelines. Interviews with the GPs after the recording period of 12 months. Adherence to each recommendation and reasons for non-adherence were measured. Results: 75 GPs actually recorded 251 patients. The GPs adhered to most recommendations in the guidelines except as regards carrying out physical examinations at both first appointment and follow-ups. Reasons for non-adherence with the physical examinations were mainly based on the GPs criticism of these recommendations. Scarcely anyone adhered to the recommmendation on follow-up appointments after ten days and a counselling consultation after six weeks. The GPs criticism of these recommendations, and the patients wishes were mentioned as reasons for non-adherence. In 9% of the cases, the GPs policy was overridden either by the patient arranging an ultra-sound scan via a locum or a midwife, or by the obstetrician taking control after the GP had requested an ultrasound scan. Conclusions: in daily practice, care providers may encounter obstacles in adherence to guidelines. As for the threatened miscarriage guidelines, the GPs criticism of the guidelines was an important reason for non-adherence, followed by the situation of the specific patient (such as medical history) and the patients wishes. Furthermore, poor collaboration between GPs, midwives and obstetricians was another obstacle in adherence. Those recommendations that are most often not adhered to should be reviewed. Furthermore, to reduce conflicts about ultrasound scans and referals, agreement on policy on threatened miscarriage should be established between GPs, midwives and obstetricians. (aut.ref.)

Implementatie van een protocol gericht op de zorgketen voor patienten met een Lumbosacraal Radiculair Syndroom

SamenvattingVolgens de NHG-standaard Lumbosacraal Radiculair Syndroom (vaak hernia genoemd) dient de huisarts de eerste zes weken een conservatief beleid te voeren. In de praktijk accepteren patiënten dit soms moeizaam. Onder andere omdat meer patiënten dan wenselijk volgens de NHG-standaard worden doorverwezen, ontstaan lange toegangs- en doorlooptijd in het ziekenhuis: gemiddeld acht en veertien weken in 1998 in het St. Annaziekenhuis in Geldrop. Daarnaast is er geen goede afstemming tussen disciplines in de behandellijn. Daardoor worden enerzijds patiënten ‘voortijdig’ verwezen; anderzijds maken patiënten met een indicatie voor verwijzing een lange wachttijd door. De voorgestelde interventie betrof een wijziging van de logistiek in het ziekenhuis en begeleiding bij de invoering van een protocol: indien de huisarts de NHG-standaard volgde, garandeerde het ziekenhuis daarna versnelde toegang tot de neuroloog en een MRI. Naast uitgebreide voorlichting werden werkafspraken en een gezamenlijke patiëntenfolder gemaakt. Bij het project waren 98 huisartsen, 150 fysiotherapeuten, vier neurologen en zes radiologen betrokken. In het artikel beschrijven we de stappen die systematisch zijn doorlopen bij de invoering en de uitkomsten van het implementatieproces. De belangrijkste conclusie is dat systematische invoering van de NHG-standaard, dat wil zeggen ondersteuning van de eerste lijn in combinatie met een logistieke reorganisatie in het ziekenhuis, mogelijk is. Het aantal voortijdige verwijzingen was laag en de gemiddelde toegangs- en doorlooptijden in het ziekenhuis namen af.AbstractImplementation of a Lumbosacral Radicular Syndrom guidelineWe carried out a feasibility study on the implementation of a LRS-guideline (Lumbosacral Radicular Syndrom) in the Geldrop region, including one hospital and all 98 GPs and 150 physiotherapists referring to this hospital. We redesigned the care process in primary care and hospital for LRS-patients. A trade off was made between the medical specialists (neurologists, radiologists) and the GPs and physiotherapists. If the GP/physiotherapist adhered to the LRS-guideline (conservative management first six weeks), after six weeks, in turn, the hospital guaranteed a priority consultation with the neurologist and priority for MRI. A determinant analysis was carried out among GPs and physiotherapists and a multifaceted implementation strategy was developed that was tailored to the critical determinants. The results showed that the number of patients being referred within six weeks, with no indication, decreased. The waiting time for first consultation with the neurologist and the duration of the total diagnostic procedure also decreased.

De ontwikkeling van implementatienetwerken

Hoe zorgen we ervoor dat een ontwikkelde richtlijn voor huisartsen daadwerkelijk door hen gebruikt wordt? Wat moeten we doen om nieuwe kennis over de optimale verzorging van wonden onder verpleegkundigen te verspreiden? En hoe krijgen we het voor elkaar dat handelingen die overbodig zijn gebleken ook werkelijk niet meer worden uitgevoerd? Dit zijn vragen die menig kwaliteitsmanager, politicus en innovator bezighouden.